Contemporary utilization patterns and outcomes of thrombolytic administration for ischemic stroke among patients with cancer.

BACKGROUND: Thrombolytic therapy significantly improves outcomes among patients with acute ischemic stroke. While cancer outcomes have dramatically improved, the utilization, safety, and mortality outcomes of patients with cancer who receive thrombolytic therapy for acute ischemic stroke are unknown. METHODS: Using a national database, we identified all hospitalizations for acute ischemic stroke requiring thrombolytic therapy between 2003 and 2015. Patients with contraindications to thrombolytic therapy were excluded. Following propensity score matching for comorbidity burden, trends in thrombolytic therapy use and its effect on in-hospital mortality, intracranial or all-cause bleeding, and the combined endpoint of mortality and all-cause bleeding, by presence/absence of cancer were evaluated. We also evaluated 30- and 90-day readmission rates post-thrombolytic therapy administration. RESULTS: We identified 237,687 acute ischemic stroke hospitalizations requiring thrombolytic therapy, of which 26,328 (11%) had an underlying cancer. Over the study period, thrombolytic therapy use increased across all acute ischemic stroke admissions, irrespective of cancer presence (12.4/1000 in 2003 to 81.1/1000 in 2015, P < 0.0001). However, thrombolytic therapy utilization differed by cancer presence (4.8% cancer vs.·5.1% non-cancer, P = 0.001). There was no difference in intracranial bleeding (9.6% vs. 9.7%), all-cause bleeding (13.2% vs. 13.2%), or in-hospital mortality (7.6% vs. 7.2%). While there was no difference in 30-day readmission rates by cancer presence (24% vs. 29%, P = 0.40), at 90-days, cancer patients saw higher readmission rates (17.2% vs. 13.3%, P = 0.02). CONCLUSIONS: Contemporary thrombolytic therapy use for acute ischemic stroke has risen, irrespective of presence of cancer. Yet, patients with comorbid cancer appear to see lower rates of thrombolytic therapy use for acute ischemic stroke, despite no difference in the rate of intracranial bleeding or mortality after adjustment for comorbidities.

Subaortic Membranes in Patients With Hereditary Hemorrhagic Telangiectasia and Liver Vascular Malformations.

Background Patients with hereditary hemorrhagic telangiectasia have liver vascular malformations that can cause high-output cardiac failure (HOCF). Known sequelae include pulmonary hypertension, tricuspid regurgitation, and atrial fibrillation. Methods and Results The objectives of this study were to describe the clinical, echocardiographic, and hemodynamic characteristics and prognosis of hereditary hemorrhagic telangiectasia patients with HOCF who were found to have a subaortic membrane (SAoM). A retrospective observational analysis comparing patients with and without SAoM was performed. Among a cohort of patients with HOCF, 9 were found to have a SAoM in the left ventricular outflow tract by echocardiography (all female, mean age 64.8±4.0 years). The SAoM was discrete and located in the left ventricular outflow tract 1.1±0.1 cm below the aortic annular plane. It caused turbulent flow, mild obstruction (peak velocity 2.8±0.2 m/s, peak gradient 32±4 mm Hg), and no more than mild aortic insufficiency. Patients with SAoM (n=9) had higher cardiac output (12.1±1.3 versus 9.3±0.7 L/min, P=0.04) and mean pulmonary artery pressures (36±3 versus 28±2 mm Hg, P=0.03) compared with those without SAoM (n=19) during right heart catheterization. Genetic analysis revealed activin receptor-like kinase 1 mutations in each of the 8 patients with SAoM who had available test results. The presence of a SAoM was associated with a trend towards higher 5-year mortality during follow-up. Conclusions SAoM with mild obstruction occurs in patients with hereditary hemorrhagic telangiectasia and HOCF. SAoM was associated with features of more advanced HOCF and poor outcomes.

Impact of left ventricular assist devices and heart transplants on acute myocardial infarction and heart failure mortality and readmission measures.

BACKGROUND: Concern has been raised about consequences of including patients with left ventricular assist device (LVAD) or heart transplantation in readmission and mortality measures. METHODS: We calculated unadjusted and hospital-specific 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates for all Medicare fee-for-service beneficiaries with a primary diagnosis of AMI or HF discharged between July 2010 and June 2013. Hospitals were compared before and after excluding LVAD and heart transplantation patients. LVAD indication was measured. RESULTS: In the AMI mortality (n = 506,543) and readmission (n = 526,309) cohorts, 1,166 and 1,016 patients received an LVAD while 3 and 2 had a heart transplantation, respectively. In the HF mortality (n = 1,015,335) and readmission (n = 1,254,124) cohorts, 789 and 931 received an LVAD, while 212 and 202 received a heart transplantation, respectively. Less than 2% of hospitals had either ≥6 patients who received an LVAD or, independently, had ≥1 heart transplantation. The AMI mortality and readmission cohorts used 1.8% and 2.8% of LVADs for semi-permanent/permanent indications, versus 73.8% and 78.0% for HF patients, respectively. The rest were for temporary/external indications. In the AMI cohort, RSMR for hospitals without LVAD patients versus hospitals with ≥6 LVADs was 14.8% and 14.3%, and RSRR was 17.8% and 18.3%, respectively; the HF cohort RSMR was 11.9% and 9.7% and RSRR was 22.6% and 23.4%, respectively. In the AMI cohort, RSMR for hospitals without versus with heart transplantation patients was 14.7% and 13.9% and RSRR was 17.8% and 17.7%, respectively; in the HF cohort, RSMR was 11.9% and 11.0%, and RSRR was 22.6% and 22.6%, respectively. Estimations changed ≤0.1% after excluding LVAD or heart transplantation patients. CONCLUSION: Hospitals caring for ≥6 patients with LVAD or ≥1 heart transplantation typically had a trend toward lower RSMRs but higher RSRRs. Rates were insignificantly changed when these patients were excluded. LVADs were primarily for acute-care in the AMI cohort and chronic support in the HF cohort. LVAD and heart transplantation patients are a distinct group with differential care requirements and outcomes, thus should be considered separately from the rest of the HF cohort.

National Trends in Incidence and Outcomes of Patients With Heart Failure Requiring Respiratory Support.

Despite increasing medical complexity in patients with heart failure (HF), there are limited data on incidence and outcomes for patients with HF needing respiratory support. This study sought to examine contemporary trends of respiratory support strategies among patients with HF. Using the National Inpatient Sample, we identified adults aged greater than 18 years hospitalized with a primary diagnosis of HF. We assessed for trends in the use of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV), length of stay, hospital costs, and in-hospital mortality. From 2002 to 2014, we identified 9,508,768 HF hospitalizations, which included 202,340 (2.13%) and 257,549 (2.71%) patients that required IMV and NIV, respectively. Over the study period, the proportion of HF patients requiring IMV significantly decreased (3.25% in 2002 to 1.56% in 2014) whereas the use of NIV significantly increased from 0.95% to 7.25% (ptrend <0.001 for both). In-hospital mortality significantly increased for IMV (31.5% in 2002 to 38.6% in 2014) recipients and decreased for patients requiring NIV (9.0% to 5.6%, ptrend <0.0001 for both). The average length of stay was nearly 7 days longer in the IMV group (12.2 days) and 2 days longer in the NIV group (6.8 days; p <0.001 for both). Hospital charges have nearly tripled for patients requiring IMV ($99,358 in 2014, ptrend <0.001) and doubled for those requiring NIV ($37,539 in 2014, ptrend <0.001). In conclusion, respiratory support strategies for patients with HF have significantly evolved with increasing use of NIV as compared with IMV. However, the in-hospital mortality associated with respiratory failure remains unacceptably high.

Cervical Spondylotic Myelopathy: Natural Course and the Value of Diagnostic Techniques -WFNS Spine Committee Recommendations.

OBJECTIVE: This study presents the results of a systematic literature review conducted to determine most up-to-date information on the natural outcome of cervical spondylotic myelopathy (CSM) and the most reliable diagnostic techniques. METHODS: A literature search was performed for articles published during the last 10 years. RESULTS: The natural course of patients with cervical stenosis and signs of myelopathy is quite variable. In patients with no symptoms, but significant stenosis, the risk of developing myelopathy with cervical stenosis is approximately 3% per year. Myelopathic signs are useful for the clinical diagnosis of CSM. However, they are not highly sensitive and may be absent in approximately one-fifth of patients with myelopathy. The electrophysiological tests to be used in CSM patients are motor evoked potential (MEP), spinal cord evoked potential, somatosensory evoked potential, and electromyography (EMG). The differential diagnosis of CSM from other neurological conditions can be accomplished by those tests. MEP and EMG monitoring are useful to reduce C5 root palsy during CSM surgery. Notable spinal cord T2 hyperintensity on cervical magnetic resonance imaging (MRI) is correlated with a worse outcome, whereas lighter signal changes may predict better outcomes. T1 hypointensity should be considered a sign of more advanced disease. CONCLUSION: The natural course of CSM is quite variable. Signal changes on MRI and some electrophysiological tests are valuable adjuncts to diagnosis.

Predictive Abilities of Machine Learning Techniques May Be Limited by Dataset Characteristics: Insights From the UNOS Database.

BACKGROUND: Traditional statistical approaches to prediction of outcomes have drawbacks when applied to large clinical databases. It is hypothesized that machine learning methodologies might overcome these limitations by considering higher-dimensional and nonlinear relationships among patient variables. METHODS AND RESULTS: The Unified Network for Organ Sharing (UNOS) database was queried from 1987 to 2014 for adult patients undergoing cardiac transplantation. The dataset was divided into 3 time periods corresponding to major allocation adjustments and based on geographic regions. For our outcome of 1-year survival, we used the standard statistical methods logistic regression, ridge regression, and regressions with LASSO (least absolute shrinkage and selection operator) and compared them with the machine learning methodologies neural networks, naïve-Bayes, tree-augmented naïve-Bayes, support vector machines, random forest, and stochastic gradient boosting. Receiver operating characteristic curves and C-statistics were calculated for each model. C-Statistics were used for comparison of discriminatory capacity across models in the validation sample. After identifying 56,477 patients, the major univariate predictors of 1-year survival after heart transplantation were consistent with earlier reports and included age, renal function, body mass index, liver function tests, and hemodynamics. Advanced analytic models demonstrated similarly modest discrimination capabilities compared with traditional models (C-statistic ≤0.66, all). The neural network model demonstrated the highest C-statistic (0.66) but this was only slightly superior to the simple logistic regression, ridge regression, and regression with LASSO models (C-statistic = 0.65, all). Discrimination did not vary significantly across the 3 historically important time periods. CONCLUSIONS: The use of advanced analytic algorithms did not improve prediction of 1-year survival from heart transplant compared with more traditional prediction models. The prognostic abilities of machine learning techniques may be limited by quality of the clinical dataset.

Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England.

INTRODUCTION: E-consultations (e-consults) were implemented at VA medical centers to improve access to specialty care. Cardiology e-consults are among the most commonly requested, but little is known about how primary care providers (PCPs) use cardiology e-consults to access specialty care. METHODS: This is a retrospective analysis of 750 patients' medical charts with cardiology e-consults requested by medical providers (October 2013-September 2015) in the VA New England Healthcare System. We described the patients and referring provider characteristics, and e-consult questions. We reviewed cardiologists' responses and examined their recommendations. RESULTS: Among the 424 e-consults requested from PCPs, 92.7% were used to request answers to clinical questions, while 7.3% were used for administrative purposes. Among the 393 e-consults with clinical questions, 60 e-consults were regarding preoperative management; these questions most commonly addressed general risk assessment (n = 44), anti-coagulation/anti-platelet management (n = 33), and EKG interpretation (n = 20). Cardiologists provided answers for the majority (89.6%) of clinical questions. Among the e-consults in which cardiologists did not provide answers or clinical guidance (n = 41), the reasons included missing or insufficient clinical information (n = 18), medical complexity (n = 6), and deferment to the patient's non-VA primary cardiologist (n = 7). Cardiologists recommended that the patients be seen as face-to-face consults for 7.9% of e-consults. DISCUSSION: Primary care providers are the most frequent requesters of cardiology e-consults, using them primarily to obtain input on clinical questions. Cardiologists did not provide answers for one in ten, owing principally to insufficient available clinical information. Educating PCPs and standardizing the template for requesting e-consultation may help to reduce the number of unanswered e-consults.

National Landscape of Unplanned 30-Day Readmissions in Patients With Left Ventricular Assist Device Implantation.

The number of patients with advanced heart failure receiving left ventricular assist device (LVAD) implantation has increased dramatically over the last decade. There are limited data available about the nationwide trends of complications leading to readmissions after implantation of contemporary devices. Patients who underwent LVAD implantation from January 2013 to December 2013 were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 37.66 from the Healthcare Cost and Utilization Project's National Readmission Database. The top causes of unplanned 30-day readmission after LVAD implantation were determined. Survey logistic regression was used to analyze the significant predictors of readmission. In 2013, there were 2,235 patients with an LVAD implantation. Of them, 665 (29.7%) had at least 1 unplanned readmission within 30 days, out of which 289 (43.4%) occurred within 10 days after discharge. Implant complications (14.9%), congestive heart failure (11.7%), and gastrointestinal bleeding (8.4%) were the top 3 diagnoses for the first readmission and accounted for more than a third of all readmissions. Significant predictors of readmissions included a prolonged length of stay during the index admission, Medicare insurance, and discharge to short-term facility. In conclusion, despite increased experience with LVADs, unplanned readmissions within 30 days of implantation remain significantly high.

Internal decompression for spinal stenosis (IDSS) for decompression and use of interlaminar dynamic device (CoflexTM) for stabilization in the surgical management of degenerative lumbar canal stenosis with or without mild segmental instability: our initial results.

INTRODUCTION: Internal decompression of spinal stenosis (IDSS) and Posterior dynamic stabilization (PDS) form a bridge between decompression laminectomy alone and rigid fusion, by attempting to sustain beneficial effects of decompression and stabilization in an attempt to prevent bad effects of relentless degeneration. OBJECTIVE: To evaluate the clinical outcome in operated patient of posterior dynamic stabilization. DESIGN: Data were collected over 1 year in prospective, nonrandomized follow-up study using outcome scales. SETTING: Single surgeon, tertiary care centre in Mumbai, India. Described here is the operative technique of posterior dynamic stabilization using CoFlexTM and clinical outcome of 67 consecutive patients using Visual Analogue Scale and Oswestry Disability Score.

Software version of Roland Morris Disability questionnaire for outcome assessment in low back pain.

BACKGROUND: Developing and using the software version of existing validated paper version of patient-related outcome can go a long way in saving cost, time and effort. However, the equivalence of paper version and software versions cannot be assumed. The aim of the study is to test the equivalence between paper version and software version of Roland Morris Disability Questionnaire and its acceptability among patients. METHODS: This is a within-subject cross over equivalence study. Fifty-five patients with back pain were asked to complete the paper and software version of RMDQ in random order. Patients were included from the Neuro Spinal surgery outpatient department of Lilavati Hospital and Research Center. RESULTS: Statistical analysis of 52 patients who completed the study showed high agreement between the paper and software version of the questionnaire (intraclass correlation coefficient 0.994, 95% confidence interval (0.989-0.996)). High sensitivity and specificity of 84 and 88% of the software version was noted. About 69.2% patients preferred software version over paper version. CONCLUSION: Our study shows that software version is comparable to the paper version. It may prove to be a useful tool for epidemiological studies and patient follow-up over longer period.

Approaches to paraspinal tumours - a technical note.

Neurogenic tumours of the paraspinal space can occur in all age groups. It is common in adult population and relatively rare in elderly group. Usually they are benign, but in children, arising from the autonomic system, tends to be malignant in nature. Usually in adults, they arise from peripheral nerve sheath and are labelled as schwannomas. For a given tumour, determination of a correct surgical approach is mandatory to achieve a successful surgical outcome. Several factors like tumour size, histology, involvement of the bony spinal canal, etc. are some of the deciding factors for a correct surgical approach. Since many such tumours are benign, total excision is possible with a correct surgical approach. If the tumour involves the integrity of the spine then additionally a stabilization procedure may have to be carried out. Unfortunately, there are still no guidelines regarding the choice of surgical approach for the excision of such tumors. Presented here is a series of five patients managed by us over a period of 10 years. Four patients were adults and one female child was three years old. Four patients were operated upon successfully and the fifth one is waiting for surgery.

Nerve root anomalies detected intra-operatively technical nuances towards achieving a successful surgical outcome: our experience of three case reports at a tertiary level centre.

OBJECTIVE: Analysis of three case reports of nerve root anomalies detected intra-operatively and its implications. DESIGN: Data collected during one year prospective non-randomised study using hospital records. SETTING: Single tertiary care centre. SUBJECTS: 3 patients in one year period.

Visual identification of coronary calcifications on attenuation correction CT improves diagnostic accuracy of SPECT/CT myocardial perfusion imaging.

BACKGROUND: Coronary artery calcium (CAC) is a powerful CAD risk marker when assessed by dedicated calcium scoring CT scan. We assessed diagnostic implications of CAC visible on attenuation correction CT scans (CTAC) from SPECT/CT myocardial perfusion imaging (MPI). METHODS: Visual presence or absence of CAC was assessed on CTAC in 1047 consecutive patients undergoing SPECT/CT MPI. Accuracy of MPI was assessed in patients undergoing invasive coronary angiography (ICA) within 1 year (n = 109). Outcomes were identified by retrospective chart review. RESULTS: Prevalence of true positive SPECT/CT MPI studies was greater among patients with CAC on CTAC (70% vs 16%; p < .001); prevalence of false positive studies was greater among those without (68% vs 15%; p < .001). PPV of MPI was 0.82 in patients with CAC, but only 0.19 in those without. Within median follow-up of 27.7 months, patients with CAC had higher all-cause mortality (6% vs 0.4%; p < .001), more late revascularizations (8% vs 0.4%; p < .001), and more MI (5% vs 0.2%; p < .001). Hazard ratio for all-cause mortality, MI, or late revascularization was 22.7 (p < .001) for patients with CAC vs those without. CONCLUSIONS: Visual assessment of CAC on CTAC should be performed during SPECT/CT MPI because it affects diagnostic certainty and may improve risk stratification.

The response of FDG uptake to immunosuppressive treatment on FDG PET/CT imaging for cardiac sarcoidosis.

BACKGROUND: Immunosuppression is used to treat cardiac sarcoidosis, despite limited data. FDG PET/CT is used for detecting cardiac inflammation in patients with CS, yet there is variability in interpretation of FDG PET/CT. Our aim was to compare quantitative and qualitative interpretation of FDG PET/CT for CS in defining the FDG response to immunosuppression. METHODS AND RESULTS: Patients with CS (N = 43 total studies from 17 patients) had serial FDG PET/CT studies before/after immunosuppression. FDG uptake was analyzed qualitatively (visually; FDG-positive segments) and quantitatively (SUVmax; cardiac metabolic volume and activity (CMV, CMA); volume above SUV thresholds 2.7 and 4.1 g/mL). Complete resolution of FDG uptake was common using CMA (10/17), CMV (10/17), but a 2.7 g/mL SUV threshold (13/17) and SUVmax (14/17) were more likely to define partial responses. In six patients imaged after a reduction in immunosuppression, 4/6 had a rebound quantitative FDG uptake. CONCLUSIONS: Quantitative interpretation of FDG PET/CT in CS can detect changes in FDG uptake in response to immunosuppression. Further studies are needed to see if quantitative changes in FDG uptake are associated with improved outcomes.

Impact of Paravalvular Aortic Insufficiency on Left Ventricular Remodeling and Mortality after Transcatheter Aortic Valve Replacement.

BACKGROUND: Paravalvular aortic regurgitation (PAR) remains a common complication following transcatheter aortic valve replacement (TAVR), and has been associated with increased mortality. Adverse left ventricular (LV) remodelling has been reported in patients with post-TAVR PAR, but the association between adverse LV remodeling and increased mortality remains unclear. The aim of the present study was to examine the association between PAR, LV remodeling and mortality following TAVR in a non-PARTNER (Placement of Aortic Transcatheter Valves) trial population. METHODS: A total of 195 patients that underwent TAVR was included in the study. The LV ejection fraction (LVEF), LV mass index (LVMI), LV internal dimension at systole (LVIDs) and diastole (LVIDd) were compared between patients with different degrees of PAR at baseline, and at one month and one year after TAVR. Survival analysis was performed for different degrees of PAR and LV remodeling. RESULTS: PAR ≥moderate was associated with increased mortality (HR 4.58 [1.80-11.63], p = 0.001), but PAR >mild was not. The LVIDd and LVIDs were persistently increased at one year after TAVR in patients with PAR >mild compared to those with PAR ≤mild (5.9 ± 0.8 cm versus 5.4 ± 0.7 cm, p = 0.02 and 4.4 ± 0.8 cm versus 3.9 ± 0.8, p = 0.03, respectively). The LVEF was improved similarly between the two groups at one year after TAVR (p = 0.1). Patients with PAR ≥moderate had significantly more adverse LV remodeling at one month after TAVR in terms of LVIDd, LVIDs, and LVMI. The degree of remodeling as expressed in terms of LVIDd, LVIDs, LVMI and LVEF changes from baseline did not have a direct impact on mortality. CONCLUSIONS: A worse PAR was associated with more adverse LV remodeling and a higher mortality after TAVR in a non-PARTNER patient population.

National Trends and Impact of Acute Kidney Injury Requiring Hemodialysis in Hospitalizations With Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a common cause for hospitalization, but there are limited data regarding acute kidney injury requiring dialysis (AKI-D) in AF hospitalizations. We aimed to assess temporal trends and outcomes in AF hospitalizations complicated by AKI-D utilizing a nationally representative database. METHODS AND RESULTS: Utilizing the Nationwide Inpatient Sample, AF hospitalizations and AKI-D were identified using diagnostic and procedure codes. Trends were analyzed overall and within subgroups and utilized multivariable logistic regression to generate adjusted odds ratios (aOR) for predictors and outcomes including mortality and adverse discharge. Between 2003 and 2012, 3751 (0.11%) of 3 497 677 AF hospitalizations were complicated by AKI-D. The trend increased from 0.3/1000 hospitalizations in 2003 to 1.5/1000 hospitalizations in 2012, with higher increases in males and black patients. Temporal changes in demographics and comorbidities explained a substantial proportion but not the entire trend. Significant comorbidities associated with AKI-D included mechanical ventilation (aOR 13.12; 95% CI 9.88-17.43); sepsis (aOR 8.20; 95% CI 6.00-11.20); and liver failure (aOR 3.72; 95% CI 2.92-4.75). AKI-D was associated with higher risk of in-hospital mortality (aOR 3.54; 95% CI 2.81-4.47) and adverse discharge (aOR 4.01; 95% CI 3.12-5.17). Although percentage mortality within AKI-D decreased over the decade, attributable risk percentage mortality remained stable. CONCLUSIONS: AF hospitalizations complicated by AKI-D have quintupled over the last decade with differential increase by demographic groups. AKI-D is associated with significant morbidity and mortality. Without effective AKI-D therapies, focus should be on early risk stratification and prevention to avoid this devastating complication.

Device success and 30-day clinical outcome in patients undergoing preimplant valvuloplasty in transfemoral versus omitting valvuloplasty in transapical transcatheter aortic valve replacement.

OBJECTIVES: The study objective was to evaluate the impact of preimplantation balloon valvuloplasty on procedural outcomes in high-risk or no-option patients with aortic stenosis undergoing Edwards Lifesciences (Irvine, Calif) Sapien valve placement. Paravalvular aortic regurgitation has been associated with long-term mortality after transcatheter aortic valve replacement. Whether omitting preimplant balloon valvuloplasty affects paravalvular aortic regurgitation after Edwards Sapien transcatheter aortic valve replacement is currently unknown. METHODS: We retrospectively analyzed the clinical outcome of 121 consecutive patients undergoing transapical (N = 50) or transfemoral (N = 71) Edwards Sapien transcatheter aortic valve replacement. Routinely, no preimplant balloon valvuloplasty was performed in transapical procedure as opposed to uniform preimplant balloon valvuloplasty in transfemoral cases. The incidence and severity of total and paravalvular aortic regurgitation and 30-day clinical outcomes were compared between the 2 cohorts. RESULTS: The average patient's age was 84.4 years, with a higher prevalence of smoking history (68% vs 42%, P = .005) and peripheral vascular disease (38% vs 20%, P = .03) in the patients undergoing transapical replacement. The preprocedural transthoracic echocardiographic and computed tomography findings were similar between the 2 cohorts. After transcatheter aortic valve replacement, the incidence of mild to moderate total aortic regurgitation (42% transfemoral vs 38% transapical), paravalvular aortic regurgitation (39% transfemoral vs 30% transapical), device success (88.7% transfemoral vs 94.0% transapical), and 30-day composite end points (9.9% transfemoral vs 14.0% transapical) were comparable in both groups. Multivariate regression analysis revealed male gender (odds ratio, 2.7; 95% confidence interval, 1.18-6.35; P = .02) but not preimplant balloon valvuloplasty as an independent predictor for mild or greater total aortic regurgitation. CONCLUSIONS: Compared with transapical transcatheter aortic valve replacement without preimplant balloon valvuloplasty, preimplant balloon valvuloplasty before transfemoral transcatheter aortic valve replacement resulted in a similar degree of prosthesis-related regurgitation, device success, and 30-day composite safety outcomes.